Faculty Spotlight: Sam Brusca, MD

Critical Care Cardiology: Harmonizing Care

Coronary Care Units (CCUs) were first established in the early 1960s for the sole purpose of caring for patients with heart attacks, also known as myocardial infarctions (MI). Since then, although MI treatments have improved, the patient population has grown older and more medically complex. And while MI care remains a staple of what is now termed the Cardiac Intensive Care Unit (CICU), there is a growing proportion of patients with non-MI diagnoses, frequently complicated by multi-organ failure. Indeed, many patients in the modern CICU have primary heart problems accompanied by other serious conditions, such as respiratory failure, renal failure and infections.

To care for these incredibly challenging, complex patients, UCSF was one of the first academic medical centers in the country to create a Section of Critical Care Cardiology. The dedicated CICU team members specialize in caring for the heart, but are simultaneously capable of managing patients’ other serious illnesses. Akin to orchestra maestros, the CICU team must synthesize all the data into a harmonious treatment plan.

“Even in a violin concerto, where the violin shines brightest, you have to direct the other instruments so that the music is balanced and beautiful,” said Sam Brusca, MD, who recently joined the UCSF faculty as a critical care cardiologist. “It’s definitely a team approach to care, and we always involve other experts; but we must funnel all the data, all the opinions into a coordinated framework that allows us to care for the whole patient.”

As a critical care cardiologist, Dr. Brusca and his CICU colleagues work closely with interventional cardiologists, cardiothoracic surgeons, advanced heart failure cardiologists, nurses, respiratory therapists, pharmacists, nutritionists and many others.

Real-Time Feedback

A native of the Washington, D.C. area, Dr. Brusca earned his bachelor’s degree in neuroscience from Washington and Lee University in Lexington, Va., and his medical degree from New York University. He then completed his internal medicine residency at Johns Hopkins in Baltimore.

He was drawn to critical care medicine because of the immediate clinical feedback of providing treatment to patients at the bedside. “We got moment-to-moment feedback on interventions, whether it was the ventilator or vasopressors or another therapy, and found out whether they were working or not,” said Dr. Brusca. “That allowed us to make treatment adjustments in a much more rapid-fire way compared to clinic, where you start a beta blocker and see the patient in a month. In the ICU, you know right away whether you’re on the right track.

“When a decision needs to be made quickly, we’re forced to base those decisions on our working hypothesis of what’s going on in that patient’s body, using the data we have,” he continued. “That’s why that rapid feedback is so crucial, because you’re not always right, and you really need to adapt quickly and pivot throughout the day…. That’s also why you want your CICU providers to be dedicated to the CICU and not have other obligations in the clinic, cath lab or elsewhere. You want them to be in the CICU all the time, ready to respond.”

After residency, Dr. Brusca completed a three-year critical care fellowship at the National Institutes of Health (NIH), where many cardiac intensivists in the nascent field of critical care cardiology have trained. “I was very lucky to go through that program, because you’re exposed to neurologic, surgical, medical, cardiac, cardiac surgical, and oncologic ICU care,” he said. “You’re prepared to subspecialize in any direction.

“My training at the NIH also provided a really strong critical care foundation for managing multi-organ dysfunction,” said Dr. Brusca. “We can institute mechanical ventilation to treat respiratory failure, provide renal replacement therapy for kidney failure, and we have a growing number of cardiac mechanical support options for those with heart failure. We were exposed to those modalities at a level of detail that many critical care programs don’t provide. By supporting those pivotal organs, we can hopefully support a patient’s perfusion, oxygenation and metabolism so that their brain and liver continue to function until the patient stabilizes. That’s a lot to keep track of. We also develop skills to avoid complications of these interventions and correctly manage care of all these organs in concert with one another.”

Shaping a New Subspecialty

After completing his critical care fellowship, Dr. Brusca came to UCSF in 2020 to do a second fellowship in cardiology. He then joined the UCSF Cardiology faculty in July 2022, recruited by Chris Barnett, MD, founding chief of the Section of Critical Care Cardiology, who also completed a critical care fellowship at the NIH and served as one of Dr. Brusca’s mentors there.

“I am excited to join a new, growing program and help to build it,” said Dr. Brusca. “There’s clearly a lot of support from UCSF and the Division of Cardiology to prioritize this new subspecialty, and that’s really necessary to create something meaningful.”

Because critical care cardiology is such a novel and disruptive subspecialty, Dr. Brusca is also active in researching its effects on clinical outcomes, and how to advance the field. Along with Dr. Barnett and another UCSF cardiac intensivist, Connor O’Brien, MD, he is a member of the Cardiac Critical Care Trials Network, which is a leading CICU registry and will hopefully sponsor future prospective trials.

Dr. Brusca worked with Dr. Barnett to conduct the first systematic survey of physicians who, like Dr. Brusca, are dually certified in both cardiovascular disease and critical care medicine. “Respondents identified critical care skills such as ventilator management, multi-organ dysfunction management, and end-of-life care as being most relevant to providing CICU patient care, and that general cardiology fellowship alone is currently insufficient to practice effectively in modern CICUs,” he said. “Hopefully this will help serve as a blueprint for development of qualifications and metrics for what a critical care cardiologist needs to know and what educational milestones they need to achieve.”

Under the leadership of Dr. Barnett, the Section of Critical Care Cardiology is currently developing curriculum to launch an advanced critical care cardiology fellowship to help build the cardiac intensivist workforce. “General cardiology fellows can elect to do an additional year of training in critical care cardiology which will be crafted to suit their specific needs and goals,” said Dr. Brusca. “We hope to build a fine-tuned educational experience that prepares trainees to operate effectively in the CICU. It will rely heavily on our strong relationship with the Division of Critical Care Medicine [within the Department of Anesthesia and Perioperative Care], because they have so much broad critical care expertise and have already created a reputable program.”

One strength of having a dedicated team of cardiac intensivists in the CICU is that they are in the hospital and at the bedside full-time. They are also well-versed in identifying the early signs of cardiogenic shock, a life-threatening condition in which the heart is suddenly unable to pump enough blood to meet the body’s needs. Richard Cheng, MD, helped to establish a shock team at UCSF in recent years, and Dr. Brusca has helped highlight how early activation of this specialized group can improve patient outcomes.

Dr. Brusca is also focused on quality improvement in CICUs. He and his collaborators recently published a paper showing that the sickest heart patients who also have non-cardiac ICU-level illnesses may actually have better outcomes in a non-cardiac ICU compared to a CICU. This may be partly because most physicians in CICUs lack expertise in general critical care. “The data seem to support having some expertise in non-cardiac illness in the CICU setting,” he said.

Cell-Free DNA and Precision Medicine

Dr. Brusca has a particular clinical and research interest in pulmonary hypertension, a type of high blood pressure which affects the lungs and the right side of the heart. He cares for these patients both in the CICU and in the UCSF Pulmonary Hypertension Clinic, one of the leading programs on the West Coast.

He conducts research focused on cell-free DNA, which are fragments of DNA released into the bloodstream from injured cells. Dr. Brusca and his collaborators used sequencing technology to identify which organs produced these distress signals and recently reported on how cell-free DNA could risk-stratify patients with pulmonary hypertension and predict survival.

He is also excited about the potential application of this biomarker to patients in the CICU, which could help critical care cardiologists identify organ damage early, when it’s easier to intervene. “For example, what if cell-free DNA started to rise well before creatinine levels rose, helping us foresee kidney injury before it became clinically apparent?” asked Dr. Brusca. “It’s a tool that could potentially give us a good amount of lead time in identifying injury, allowing us to make adjustments and maybe even prevent severe organ injury from happening.”

Because cell-free DNA can be accessed through a simple blood draw, Dr. Brusca is also excited about how it could be used one day to routinely manage CICU patients, including better diagnosing and treating shock patients. “By being able to identify the origin of circulating fragments of DNA, we could create a map for each individual patient of which organs or cell lines are injured,” he said. “That sort of precision medicine is the Holy Grail, both for understanding patients’ pathophysiology and potentially for tailoring specific therapies. It is possible that patients with certain patterns of organ injury might respond better to one medication as opposed to another. Hopefully this will help put us at the forefront of the scientific exploration of undifferentiated shock and precision medicine. UCSF has a lot of tools at its disposal and is a very powerful research institution. We’re very well set up to potentially change the way people approach shock in general.”

Pursuing his Passions

Dr. Brusca feels fortunate to have worked with mentors who encouraged him to follow his passions. “Early on, I was trying to decide between pulmonary medicine and cardiology,” he said. “I was very lucky that some of my residency mentors told me, ‘If you want to do cardiology and ICU, why don’t you do both?’ Especially within academics, there’s a lot of flexibility to choose your own adventure. You can build a career and academic portfolio that suits you and sets you up for long-term success, because it satisfies your inner curiosity and clinical interests.”

“Sam Brusca is one of the best and brightest… who brings to UCSF extraordinarily broad critical care and cardiology skills, as well as a promising research program,” said Henry Masur, MD, chief of the Critical Care Medicine Department at the NIH Clinical Center and one of Dr. Brusca’s longtime mentors.

“We are thrilled that Dr. Brusca has joined our critical care cardiology section at UCSF,” said Dr. Barnett. “Already, during his fellowships in critical care medicine and cardiology, Sam has accomplished much, and we look forward to his educational, research and clinical contributions to our section at UCSF and more broadly to the new specialty of critical care cardiology.”

“I’m very excited to be joining a nascent but supported critical care cardiology program that I believe will soon become one of the nation’s leading centers,” said Dr. Brusca. “I hope we’ll be able to build a cutting-edge precision medicine research portfolio to improve care of critically ill cardiac patients, and to help the field grow and evolve by training the next generation of cardiac intensivists.”

Prior to becoming a doctor, Dr. Brusca was on his high school and college wrestling teams, and he has also volunteered as a wrestling coach. He is married to Rebeccah Brusca, MD, MPH, a hospitalist at Zuckerberg San Francisco Hospital. Together they have two young children.

- Elizabeth Chur